LAST UPDATE | 22 Apr

A RETIRED NURSE manager at University Hospital Limerick (UHL) told Aoife Johnston’s inquest today that the hospital was akin to a “war-zone” and “unsafe” for patients on the night the 16-year old Co Clare teenager presented there, before she eventually died of sepsis after waiting on a chair for 12 hours.

Katherine Skelly, a clinical nurse manager at the Limerick Emergency Department, with 23 years experience, provided a damning insight into the chaotic scenes inside UHL over that weekend.

Skelly said the hospital was overwhelmed due to an influx of acutely ill patients who presented with multiple fractures during a severe weather freeze alert.

She said the “crisis” which unfolded at the hospital was “very clear and alarming”.

“What I observed was akin to a war-zone. Every available floor space was taken up, trollies were lined up next to each other, blocking doors.”

“Paediatrics was grossly overcrowded; The seven bays in Resus were all full plus there were seven more patients there on the floor space, some were attached to defibrillators.”

“We were in a crisis situation, it was a major incident status in my opinion.”

In a SOS call to a more senior nurse manager, she said: “This is a major emergency, we need help.” She requested trolleys be sent out of the ED and onto to wards but this was not done.

“I deemed it a serious and immediate risk to patients.”

Skelly said there were 67 “category two” patients in the ED, including Aoife, who she agreed she deemed to be “dangerously ill” patients.

She said Aoife Johnston and these 66 other seriously ill patients were waiting more than ten hours to see a doctor when the recommend standard waiting time for Category Two patients was “15 minutes”.

She said she telephoned an on-call consultant and told him of the risks to patients and asked him to come to the emergency department, but she said, “he declined my request”.

Another consultant initially declined to come to the ED but arrived later on.

‘Unsafe’

“Resus was alarmingly unsafe,” Skelly said.

When finishing her shift on 16 December 2022, the night before Aoife Johnston presented at the hospital, there were “130 patents” in the ED, she said.

She said she had expected the situation would have been “de-escalated” upon her return to work the following night but it had not, and “there were 160 patients” in the ED.

She requested staff support as there were “fifteen nurses” on duty in the ED and Resus area, when according to the recommended standards, “there should have been 20 nurses” on duty.

“We could have done with 30, such was the volume of patients,” she said. Three nurses were assigned to Resus when the “minimum cover” is four.

When Aoife Johnston presented with sepsis with her parents they laid her across two chairs together because there were no trolleys available.

Skelly told how patients were sandwiched together cheek by jowl on trolleys, some, including children, were “sitting on the floor” due to a lack of space.

All the while Aoife Johnston was “dying in front of the staff’s eyes”, said Damien Tansey, senior counsel for the Johnston family.

Skelly said in her opinion, the paediatric area was “unsafe”. She said she did not take any of her allocated break times as she and other staff members were under “constant pressure”.

“I literally did not have a moment to raw my breath.”

Skelly said the told her superiors that the department was “clinically unsafe” and that “the risk to patient safety was at a level I had not encountered before”.

Interruptions

She told how patient handovers between nurses coming on and off shift was “constantly interrupted by patients and patients families”.

“Some were extremely abusive because of the long waiting times; staff were constantly looking for support; security guards were ringing about hostile patients.”

“Some patients were horrified when they were told they would not be seen until the following morning.”

Skelly said she asked a senior doctor to stop attending fracture patients and to instead attend a child who was waiting 12 hours with suspected serious abdominal trauma.

She said she told the doctor they “could not stand over” a child waiting 12 hours while fracture patients were being attended to.

Skelly said she asked that some trauma patients be transferred to Croom Orthopaedic Hospital in county Limerick to ease pressure on UHL “but in spite of this we came on to the same crisis the following night with 190 patients on trollies”.

Staff were working under “unimaginable stress” and patients some patients received “substandard care”, while others simply “left the hospital without getting treatment”.

Skelly told the inquest: “We have become too accustomed to the (overcrowding) crisis at UHL.”

She said she and some of colleagues had long “warned” about the risks of overcrowding to patients’ lives.

“Given the staff deficits in the emergency department, it was not possible to carry out our role in a comprehensive way. Overcrowding is the norm.”

She said these “significant deficits” in staff numbers in were both “permanent” and “temporary”.

“So no roster/shift would be fully staffed”, she said, and staff would be on “acute sick-leave”.

She said a patient suspected of having sepsis should have gone straight to the Resus room.

Skelly told Tansey that she had been devastated by Aoife Johnston’s death and left her job at UHL because of it: “I never worked in A&E after that weekend.”.

“It absolutely broke me professionally and personally that that poor girl died”.

‘There was no help’

Earlier, the inquest heard emotional and harrowing testimony from Aoife Johnston’s parents, who said they watched their daughter die despite “begging” staff to help.

James Johnston wept and held his face in his hands as he told the inquest that, despite his pleadings for assistance for his daughter, UHL staff “kept giving Aoife paracetamol, and putting ice packs on her legs” but that “they just weren’t really helping, there was no help”. 

Mr Johnston said Aoife had awoken at their home on Saturday, 17 December in “great form” but she became “unwell” around midday, and “took some paracetamol and returned to bed”. 

Around 3.30pm Aoife vomited and Mr Johnston made an appointment at locum GP service Shannodoc for 4.50pm for Aoife. 

Mr Johnston said the on-call doctor, Dr Madlala Mdumiseni, told them that after examining Aoife he was “concerned” for her and he advised they go directly to UHL. 

Dr Mdumiseni, told the inquest he had formed the view that Aoife was suffering from an “acute infection of sepsis with symptoms worsening”. 

Dr Mdumiseni said Aoife “looked clinically unwell”, her heart rate was fast, her blood pressure was low, she was dehydrated, weak and lightheaded. 

Dr Mdumiseni said he gave Mr Johnston the referral letter and told him to present it at UHL to ensure Aoife would be seen “as soon as possible”. 

However, the inquest heard it was over 12 hours before Aoife was seen by a doctor. 

Mr and Mrs Johnston said they immediately brought their daughter to UHL, arriving at the hospital at 5.40pm. 

Carol Johnston said that on the way to UHL she opened the referral letter “which stated that Aoife had a temperature of 39.5 and that the doctor felt that she might have viral septicaemia and dehydration”. 

When they arrived at UHL they handed in the referral letter and were told to take a seat in reception. 

Aoife was not seen by a triage nurse – the first point of contact with medical staff – until 7.15pm, an hour and 35 minutes after presenting at the hospital. 

James Johnston said Aoife “vomited twice while waiting” for the triage nurse. 

The nurse, he said, “spent approximately five minutes with Aoife” before taking her on a wheelchair to the emergency department which, it was heard, was overcrowded with trolleys. 

“There was no trolley available, so we tried to make a bed for Aoife with two chairs,” Mr Johnston said. 

Aoife’s condition worsened but she did not receive adequate care “until it was too late”, Damien Tansey, senior counsel and solicitor for the Johnstone family said. 

Throughout the night Aoife’s skin developed blotches and became discoloured around her left eye. 

“Aoife was violently vomiting pure green liquid. I continually begged for help. The response was a brown cup for Aoife to vomit into, and on one occasion a rebuke, ‘I am well aware she is sick, but have 70 other patients to look after’,” Mr Johnston said. 

“I was up and down to the nurses all night pleading with them to help my daughter. Aoife was screaming in agony with pain in her right leg and head.” 

Mr Johnston said his daughter’s screams were so loud “that I heard people outside on the trolleys asking the nurses and doctors to help Aoife, and at one point a man said ‘is someone not going to go into that girl’.” 

Carol Johnston said that as her daughter was being brought to the emergency department, she “noticed a huge number of trolleys and I said to the nurse ‘look she’s really ill, you’re not leaving us here are you? She’s really unwell’.” 

She said Aoife was moved from Zone A at the ED to what “appeared to be a storage room as there was PPE gear all over the room”. 

“There was no trolley available, so we tried to make a bed for Aoife with two chairs,” Ms Johnston added. 

Aoife’s parents said that, at one point during the night, staff brought Aoife for an X-ray, but that “when Aoife came back, she was very upset and said that the staff were ‘really mean’ to her”. 

“She told us that they were giving out to her because she couldn’t stand up but by that point Aoife was physically unable to stand”. 

Tansey said his clients were adamant Aoife was brought for the X-ray, but he said, UHL had “no record” of the attempted scan. 

Aoife was first seen by a doctor at 6am the following morning, 18 December, and was advised she would be treated as if she had meningitis. 

At this stage, Aoife was “in agony”, her father said. 

“After the doctor left, Aoife started to deteriorate even more. I went out to the nurses station and there were approximately 12 nurses just standing there, and I roared at them to help my f*****g daughter,” Mr Johnston said. 

“At this point, my daughter could no longer communicate. Aoife was taken to resuscitation, her limbs were moving involuntarily; I was asked to hold down my daughter’s legs so they (doctors) could administer treatment.” 

Doctors placed Aoife in an induced coma to reduce swelling on her brain but she was pronounced dead at 3.30pm on 19 December. 

Cross-examination

Tansey said the head nurse who was in charge of Aoife’s care was presently in Australia. She had prepared a deposition for the inquest, but she was not available to attend the hearing in person or by a Zoom call. 

Tansey said all parties had “months” of notice of the inquest date and that it was “inconceivable” that in a modern world with technology that a witness was not available to give evidence or take questions on a Zoom call. 

He said it was of “great concern” that the Johnston family would not have the opportunity to cross-examine the nurse. 

Tansey said an external interim report which was completed into Aoife’s care had been given to the HSE and UL Hospitals Group but that the Johnston family were again “concerned” that they still did not see the report and they have had to “rely” on media reports to hear its contents. 

Tansey said the Johnston family were grateful for meetings they had with the chief executive of the HSE, Bernard Gloster, and Minister for Health Stephen Donnelly. 

Conor Halpin, senior counsel, acting for the HSE, read out two letters of apology on behalf of Gloster and Colette Cowan, chief executive of the UL Hospitals Group for admitted “failings” in Aoife’s care which led to the “catastrophic” outcome of her death. 

The Johnston family also acknowledged that the nature of Aoife’s death had personally impacted Gloster.

Tansey said: “He (Gloster) was clearly emotionally moved by the nature of their tragic loss.” 

Tansey said the Johnston family were concerned Cowan, who would have clear knowledge of the running of the emergency department, was not a witness at the inquest. 

Coroner John McNamara said Cowan was not asked to provide a deposition and that depositions provided by UHL staff who were directly involved in Aoife’s care would be heard. 

Carol Johnston concluded her deposition, telling the court: “I continually begged for help. We watched our daughter die, I wouldn’t wish it on anyone.” 

“God help her, we told her she was in the best place, but it turned out she wasn’t.” 

The inquest is scheduled to run for four consecutive days.